Blood transfusion is one of the most commonly prescribed procedures by many disciplines in medicine and yet there is very little formal teaching in the existing medical education curriculum. In fact there are several studies in North America and Europe that report a high percentage of blood transfusions are inappropriate. Other studies have shown that a significant number of practicing physicians and residents are not able to obtain appropriate consent for transfusion mostly due to a knowledge gap or under- appreciation of the patient’s understanding and perception with regards to transfusion. Almost five years ago, a group of thoughtful and dedicated leaders in transfusion medicine recognized the deficiency in residents’ education and initiated a series of year-long transfusion workshops for the University of Toronto postgraduate students, dubbed as “Transfusion Camp”. This initiative soon drew the attention of the residents and the educators from other medical programs in Ontario and grew to a platform for teaching residents in various disciplines across the nation. The camp features University of Toronto educators in transfusion medicine who discuss the latest scientific findings in transfusion practice that have direct clinical impact on patient care.

I had the pleasure of participating in the 2017 transfusion camp with a group of friends and after spending a day in the camp, many of us realized that transfusion is not as simple of a procedure as we thought it was. We recognized that we all need to know a great deal more about the indications, appropriate choice of products, alternatives to transfusion and the side effects of transfusion in order to make the best possible decision for our patients. We all conceded that after the camp day, our practice and process of making decisions to transfuse blood and blood products and even the consent discussion would not be the same. Many of us felt that if we had this learning opportunity earlier we might have done things differently.

Another impressive fact about the transfusion camp apart from carefully selected content and objectives was the teaching model that was adapted. It is a combination of traditional didactic teaching and interactive learning formats that provides a forum to discuss various aspects of transfusion medicine and study real cases. The content of the lectures, videos and other educational material is also made publicly available to review prior to the course and to be used after the workshop as reference.

Witnessing the impact of the transfusion camp initiative in the daily practice of residents and subsequently improving the care we provide to patients, I think it is essential to include the transfusion education with the new camp format in the medical curriculum of all medical schools in Canada.

At the end I think it is incumbent upon me to recognize the tireless efforts of the extraordinary laboratory physicians Dr. Yulia Lin and Dr. Jeannie Callum who initiated this program and continue to strive to improve the quality of patient care by educating young physicians about transfusion.

“Hit the Repeat Button” How often is Antibody Identification required?

By Wendy Owens, ORBCoN Program Manager, NE Region

Antibody identification testing is initiated once a positive antibody screen test is detected. If a clinically significant antibody is identified, the result is reported and documented in the patient’s record. For patients who are chronic transfusion recipients, the question arises ‘Is it necessary to perform a full antibody identification each time that patient requires a crossmatch for transfusion?’

In 2017, ORBCoN performed a small ad hoc survey to ask hospitals in Ontario what their practice is with respect to repeat antibody identification testing. We received responses from 10 hospitals and they reported the following:

1 hospital reported confirmation of the presence of the previously identified antibody and exclusion of new clinically significant antibodies using selected reagent red cells in addition to performing a serologic IgG crossmatch with antigen negative donor units

3 hospitals reported they perform an antibody screen only and an IgG crossmatch with antigen negative donor units to detect the presence of any new antibodies. A more complete antibody identification is performed every two weeks

2 hospitals reported they test as above however they only repeat an antibody identification every month

One group of four hospitals reported that they perform an antibody screen and crossmatch antigen negative donor units (IgG crossmatch). As long as the crossmatch is compatible and there is no change in the strength of the existing antibody these hospitals can follow this protocol. Their policy is to repeat the full antibody investigation only every six months (recently extended from three months after reviewing their historical data).

So, what is the correct practice? Why is there such variation in the approach taken? Is it acceptable to just perform an antibody screen and crossmatch antigen negative units if the patient has a previously identified clinically significant antibody?

What do the Standards say about this?
Canadian Standards state that when a clinically significant antibody has been identified, red blood cells that lack the corresponding antigen should be selected for transfusion and be shown to be compatible by serological crossmatch.1,2,3

It appears that all of the hospital reported practices comply with the minimum required by Standards, therefore all should be considered acceptable. As resources for hospital transfusion services become scarce, hospitals often need to adjust their practice to conserve these resources. Standards help ensure that decisions made will not jeopardize patient care and will ensure that practice is safe.

As far as determining the frequency of performing a repeat antibody investigation to detect the presence of a new antibody in patients who have been recently transfused, many hospitals elect to use antibody screening cells to check if there are any unexpected reactions (any reactivity with antigen negative cell detected or change in strength of reactions) in addition to compatibility testing of antigen negative units.

The justification for this being that if a new antibody has developed, the antigen compatible units plus the additional screening cells would provide evidence of a new antibody should unexpected positive reactions be detected. While this practice would be acceptable 4 for most cases, when a patient has developed antibodies against multiple antigens or to a high frequency antigen, screening cells may not provide a good indication if there is another underlying antibody present. Also, to be considered, if the new antibody reacts only with homozygous expressions of the corresponding antigen, the donor units selected for crossmatch may still appear to be compatible. Each hospital should perform a risk assessment to evaluate if the policy they select poses any risk to patient safety prior to implementing it. If an abbreviated investigational approach is adopted, monitoring for possible increased patient risk should take place to ensure the new policy is not causing increased patient harm. For example, monitor transfusion reaction rates.

While there is an argument to be made for standardizing processes, it is also important to accept that each hospital must have the flexibility to make decisions based on their own rationale and evaluation. So who is right? All of these practices can be considered acceptable. To repeat or not doesn’t necessarily have to be the question!

We encourage hospitals to share any results of their risk assessments by writing an article for the ORBCoN report and/or more formal publications. This may help other sites in considering if they should make a change to their current policy.

References:

CSA Z902-15 Canadian Standards Association Standards for Blood and Blood Components December 2015; CSA Group